The state of the Ireland’s maternity services is deeply unsatisfactory. In August of last year, in considerable frustration and anger at the lack of any cohesive action to make improvements, I wrote to the Irish Times (letter) to describe the situation. By budget time, it was already known that several large maternity hospitals had had their busiest month of August ever, and the number of bookings was increasing so that 2008 would be busier still. Senior clinicians at the maternity hospitals were all extremely worried that mortality rates, maternal as well as perinatal, would inevitably rise. In introducing the budget, the Ministers of Health and Finance recognised that there was indeed an emerging problem. The result was that not an extra red cent was voted for the maternity services. In December, the Irish Times published a very powerful editorial which stated:
“The lives of mothers and infants are being put at risk because of staff shortages and inadequate facilities at our maternity hospitals. What should be a time of joy and celebration for families may be blighted as a result of funding deficiencies and official inaction. It is an appalling situation. Unless these shortcomings are addressed as a matter of urgency, the situation will worsen as our population continues to expand.”
Still no action.
This week (Irish Times report), Padraic Flanagan’s testimony to the inquest on the death of his wife, Evelyn, allegedly because of obstetric haemorrhage after the birth of their second child at Castelbar General Hospital in October last year, sadly echoes this statement. “What should have been a joyous occasion for us all has turned into the most tragic of our lives with repercussions that will last for years,” he said.
Obstetricians regard maternal deaths from haemorrhage as mostly avoidable. The UK Healthcare Commission inquiry into a series of maternal deaths, several from haemorrhage, at Northwick Park Hospital in London between 2002 and 2004 found that inadequate staffing and an excessive reliance on locum staff were contributory factors.
The Increase in Births
The number of babies born in Ireland in 2007 was over 72,000, an increase of 12.5% on 2006, and a 38% increase on the 52,000 births in 1997. The high birth rate is the result of demographic changes – immigration of healthy young people into the country and the large number of people in their twenties and thirties in the population. The last peak in births was in the late seventies and early eighties – the babies born then are having their own families now. It is possible, with some immigrants returning home, that there may be a small decrease in 2009, but the greater likelihood is that the current high birth rate will continue for another decade. Some 75,000 babies will be delivered in 2008 with basically the same inadequate facilities that existed for the 52,000 born in 1997.
The problems in the maternity services relate to the inadequate capacity of largely out of date hospitals. There are both staffing and infrastructural deficits. The first new maternity hospital in many decades was opened by the Minister in Cork in the spring of 2007. Cork University Maternity Hospital, after many years in planning, was supposed to have a capacity of 7000 births per annum: by the end of its first twelve months in operation, it had already delivered 8500 babies. The Limerick hospital is designed for 3000-3500 births – this year we will have 5500. The three Dublin maternity hospitals will each deliver close to 9000 babies this year.
Ireland has about 100 consultant obstetricians, 2.2 per 100,000 population; this is by far the worst ratio in the EU, where the next worst is the Netherlands with 4.5 per 100,000 (Eurostat data). The situation is even worse than that because Ireland has the highest number of births per 1000 in the EU. Switzerland has 1000 obstetricians for roughly the same number of births as Ireland. Similarly, the number of consultant neonatologists is very poor. We rely heavily on the services of junior doctors in training and locum consultants to bridge the gap.
Free Standing Maternity Hospitals
Four of the country’s largest maternity units, the National Maternity Hospital (Holles St), the Coombe, the Rotunda and Mid-Western Regional in Limerick are free standing hospitals on sites remote from general hospitals. They do not have direct access to the highly specialised services required by some mothers, particularly ICU. These buildings are all out of date. The masters of the three Dublin maternity hospitals and the consultants in Limerick are very anxious to relocate their hospitals on to the sites of general hospitals because of issues of patient safety – the transfer by ambulance of critically ill mothers to ICU is a particular concern. The four hospitals occupy valuable sites the sale of which would go a long way towards the cost of relocating them.
Neonatal Intensive Care Units
All of the country’s major neonatology units are under extreme pressure and are frequently closed because they are already full. Desperate staff spend hours phoning around to find ICU cots for babies likely to be born prematurely when their own unit is packed. Neonatal transport and retrieval facilities are poorly developed.
Crowding and Lack of Privacy
Single-patient rooms are a minimum standard for all obstetrical hospitals according to American Institute of Architects 2006 guidelines. France has adopted a single-patient room standard for all new hospital construction for the last 20 years. In Limerick, five public patients share a single crowded room with one toilet and shower. Some hospitals have even larger public wards. Privacy is only for private patients.
With the ratio of consultants to mothers so low (each consultant is responsible for an appalling average of 700 annual deliveries), the service offered is just about ‘consultant-led’, rather that consultant delivered. We rely heavily on junior doctors in training. In this highly unsatisfactory supply and demand situation, only private patients and the highest risk public patients get access to consultants.
Reports Gathering Dust
The HSE commissioned the Institute of Obstetricians and Gynaecologists to compile a report on the future of maternity services in Ireland. It was published in 2006. Among a large number of recommendations, it called for a large increase in the number of obstetricians. It is gathering dust. The KPMG report on the maternity services in Dublin is still awaited more than a year after it was completed. It will have nothing to say about services outside of Dublin, where the majority of births take place.
It is beyond belief that this rich country cannot provide women having babies with a reasonable standard of maternity care. It is even further beyond belief that the members of the government can recognise that there is an emerging crisis and take no action whatsoever. What are they there for? They should be ashamed of themselves.
Dr Gerry Burke, FRCOG, is a consultant obstetrician & gynaecologist in Limerick’s Regional and Maternity Hospitals. He is also a member of the Labour Party.
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